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Intake Detail
Elena Vasquez New
Call today1. General Information
Pending
1
Demographics
2
Contact Information
3
Reason for Visit
2. Callback
Pending
1
Preferred Times
Afternoons (12pm-5pm), Tomorrow morning around 10am
Modification History
"Afternoons (12pm-5pm), Tomorrow morning around 10am"
2
Callback Schedule
Next Scheduled Callback
No callback scheduled
Call History
1
Jan 21, 10:30 AM
No answer
Left voicemail with callback number
Jordan Lee
3
Complete Callback
Callback Completion
Not completed yet
Clerk
Called patient at 10:30 AM, no answer. Left voicemail.
3. Insurance Coverage
Pending
1
Insurance Info
or use structured fields
2
Confirmation
Coverage Status
Not confirmed yet
Confirmation History
No history yet
Clerk
Verified insurance: BlueCross BlueShield PPO. $30 copay.
4. Form
PendingChoose form type:
1
Send Form to Patient
Not started
2
Form Received
Not started
3
Confirm Signed
Not started
4
Scanned
Not started
5
Archived
Not started
1
Send Form to Patient
Not started
2
Form Received
Not started
3
Confirm Signed
Not started
4
Archived
Not started
5. Booking
PendingFirst Appointment
Not yet scheduled
User Submitted Information
Original Submission - Jan 21, 2026 at 9:15 AM
Name
Elena Vasquez
Phone
(555) 123-4567
Email
elena.vasquez@email.com
Source
Public Portal (INT-7842)
Preferred Times
Afternoons (12pm-5pm)
Referral
Dr. Martinez (primary care)
Patient's Message
Referred by Dr. Martinez. Experiencing increased anxiety affecting sleep and work. Interested in CBT. Prefers female therapist.